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Nonfatal Choking-Related Episodes Among Children --- United States, 2001

Food and nonfood substances can present a choking hazard for children, particularly younger children
(1,2). During 2000, the latest year for which national mortality data were available, 160 children aged
<14 years died from obstruction of the respiratory tract associated with inhaled or ingested foreign bodies
(International Classification of Diseases, Tenth
Revision, codes W79--W80); food and nonfood substances were associated with 41% and 59% of these deaths, respectively
(CDC, unpublished data, 2002). To characterize nonfatal choking-related episodes in children treated in U.S. hospital
emergency departments (EDs) during 2001, CDC analyzed data from the National Electronic Injury Surveillance System-All
Injury Program (NEISS-AIP). This report summarizes the results of this analysis, which indicate that an estimated 17,537
children aged <14 years were treated in EDs for choking-related episodes in 2001. Many of these episodes were associated with
candy/gum (19.0%) and coins (12.7%). Parents and caregivers should be aware of the types of foods and objects that pose a
choking risk for children, become familiar with methods to reduce this risk, and be able to treat choking in children.

NEISS-AIP is operated by the U.S. Consumer Product Safety Commission and collects data on initial visits for all
types and causes of injuries treated in U.S. EDs
(3). NEISS-AIP data are drawn from a nationally representative subsample of
66 (out of 100) NEISS-AIP hospitals, which were selected as a stratified probability sample of hospitals with a minimum of
six beds and a 24-hour ED in the United States and its territories. NEISS-AIP provides data on approximately 500,000
injury- and consumer product--related ED cases each year.

Cases in this report occurred among patients aged
<14 years treated for unintentional, nonfatal choking-related episodes
in which the external cause of injury was coded as inhalation or suffocation, or a brief narrative describing the episode
included "choke," "choked," or "choking." Patients were excluded if the episode was related to smoke inhalation, choking on
secretions or vomitus, submersion injury, strangulation, breath-holding spell, exposure to a toxic or noxious substance, or
poisoning. Because deaths are not captured completely by NEISS-AIP, children who were dead on arrival or who died in EDs also
were excluded. The narratives were reviewed for all cases to classify, when possible, the food and nonfood substances
associated with the choking episode.

Each case was assigned a sample weight based on the inverse probability of selection; these weights were added to
provide national estimates of choking-related episodes. Estimates were based on weighted data for 526 children with
choking-related episodes treated at NEISS-AIP hospital EDs during 2001. Confidence intervals (CIs) were calculated by using a
direct variance estimation procedure that accounted for the sample weights and complex sample design. Rates were calculated
by using 2001 U.S. Census Bureau population estimates.

In 2001, an estimated 17,537 (95% CI=12,319--22,755) children aged
<14 years were treated in EDs for
choking-related episodes for a rate of 29.9 per 100,000 population (95% CI=21.0--38.8) (Table). Rates were highest for infants aged <1
year (140.4) and decreased with age. The rate for boys (32.1) was similar to that for girls (27.3). Although the majority of
patients were treated and released, 1,844 (10.5%; 95% CI=3.1--18.0) were hospitalized or transferred to a facility with a higher
level of care.

Of the 17,537 children treated in EDs, 10,438 (59.5%; 95% CI=39.3%--79.7%) were treated for choking on a
food substance, 5,513 (31.4%; 95% CI=18.0%--44.9%) on a nonfood substance, and 1,586 (9.0%; 95% CI=4.1%--14.0%) on
an undetermined substance. Of overall choking-related cases, 2,229 (12.7%; 95% CI=5.0%--20.4%) were associated with
coins, and 3,325 (19.0%; 95% CI=12.1%--25.8%) were associated with candy/gum. Of episodes related to candy/gum,
2,153 (64.8%; 95% CI=35.5%--94.0%) were associated with hard candy, 419 (12.6%; 95% CI=3.8%--21.4%) with other
specified types of candy (e.g., chocolate and gummy candy) and gum, and 752 (22.6%; 95% CI=8.2%--37.1%) with an
unspecified candy.

Food and nonfood substances associated with choking-related episodes varied by age group. Food substances accounted
for 2,355 (75.7%; 95% CI=40.3%--111.2%) choking-related episodes among children aged 5--14 years, 5,302 (58.4%;
95% CI=37.8%--78.9%) episodes among children aged 1--4 years, and 2,781 (52.1%; 95% CI=30.7%--73.4%) episodes
among infants aged <1 year. Candy/gum was associated with approximately one fourth of choking-related episodes among
children aged 5--14 years (860 [27.6%; 95% CI=11.4%--43.9%]) and those aged 1--4 years (2,223 [24.5%; 95%
CI=14.7%--34.2%]). Coins accounted for 1,658 (18.2%; 95% CI=5.8%--30.7%) choking-related episodes among children aged
1--4 years.

Editorial Note:

This report provides national estimates of nonfatal choking-related episodes in children aged
<14 years. On the basis of national mortality data compared with estimates described in this report, for every choking-related death in
this age group, an estimated 110 children were treated for choking-related episodes in U.S. hospital EDs. Children are at risk
for infection in the respiratory tract and complications associated with lack of oxygen from airway obstruction,
including permanent brain damage and death
(4,5).

Several public health strategies can reduce the risk for choking in children, including public education,
product-safety labeling, changes in product design, and the instruction of parents and caregivers in emergency preparedness for the
early treatment of choking. Public education can increase the awareness of the problem, the items that present a choking
hazard, the ages at which children are at highest risk, and the importance of adult supervision when young children are eating
and playing. Product-safety labeling can inform consumers of potential choking dangers through age-appropriate labeling on
toys and warnings on high-risk items (e.g., balloon packages and small balls). The design of some products has changed to
reduce choking risks, such as eliminating small parts of toys designed for toddlers and nonfood toys packaged with food items.
In addition, parents and caregivers can receive instruction on treating choking from health-care providers or take courses
that teach basic lifesaving skills and first aid. Further evaluation of all of these strategies is needed to assess their effectiveness
in reducing fatal and nonfatal choking-related episodes.

Parents and caregivers can reduce choking hazards in a child's environment. Special attention should be given to food
and nonfood items (e.g., candy, nuts, and coins) commonly involved in choking. Younger children are particularly at risk
because of their tendency to place objects in their mouths, poor chewing ability, and narrow airways compared with those of
older children (1,2). Recommendations are available to guide parents and caregivers about the types of food items that
are inappropriate for children aged <4 years
(6,7). Removal of nonfood choking hazards also is important for infants and
children aged <4 years because approximately one third of all choking episodes involve nonfood items.

Because complete removal of all choking hazards is unlikely, parents and caregivers should learn how to treat a child who
is choking. A federal campaign has been launched to encourage parents and caregivers to learn early treatment of
childhood medical emergencies, including choking
(8). Early and effective treatment is crucial to prevent morbidity and mortality
from childhood choking. Methods taught routinely in courses on cardiopulmonary resuscitation (CPR) or first aid can
be lifesaving when instituted early by trained parents and caregivers
(9). Opening the airway quickly by ejecting the foreign
body can avoid potentially severe injuries. The American Academy of Pediatrics recommends that all parents and
caregivers participate in the American Heart Association's Basic Lifesaving Course or the American Red Cross' Infant/Child
CPR Course (10).

The findings in this report are subject to at least five limitations. First, the analysis included all cases in which choking
was involved. It was not possible, using information obtained in NEISS-AIP, to distinguish cases in which the child choked on
a substance that entered and blocked the airway from other cases in which the child choked as the result of
pharyngeal irritation or an esophageal foreign body. Second, this report considered only cases treated in EDs and did not include
deaths or episodes in which medical care was obtained at a physician's office or another health-care facility or was not received at
all. For example, only 55% of choking children for whom emergency medical services were contacted were transported to
EDs for care (1). Third, NEISS-AIP does not provide information on outcomes after discharge from EDs. Fourth, NEISS-AIP
is designed to provide national estimates and does not provide state or local estimates. Finally, exposure to candy, food,
and other items differs by age group and was not considered in this analysis.

Parents, caregivers, health-care providers, and the public should remain vigilant in the prevention and treatment
of choking-related episodes. Additional information about choking prevention and treatment is available from CDC's
Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control at
http://www.cdc.gov/ncipc/duip/spotlite/choking.htm.

Acknowledgments

This report is based on data contributed by T Schroeder, MS, C Downs, A McDonald, MA, and other staff of the Div of Hazard
and Injury Data Systems, U.S. Consumer Product Safety Commission. E Sogolow, PhD, Div of Unintentional Injury Prevention,
National Center for Injury Prevention and Control, CDC.

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